Effectiveness of Self-guided App-Based Virtual Reality Cognitive Behavior Therapy for Acrophobia: A Randomized Clinical Trial

Fear not: Combining digital and virtual reality interventions for the treatment of social anxiety disorder - a randomized controlled trial

INTRODUCTION

Social anxiety disorder (SAD) poses a significant mental health challenge. Despite cognitive behavior therapy being the first-line treatment for SAD, its accessibility remains limited. Internet- and mobile-based interventions (IMIs) offer approaches to enhance accessibility and reduce waiting times. As part of this, some recent approaches have incorporated virtual reality (VR) to enable behavioral experiments and exposure. This pilot study aimed to explore the efficacy of an IMI, including CBT interventions via smartphone apps and VR to alleviate the severity of SAD symptoms.

METHODS

Thirty-two patients diagnosed with SAD were randomly assigned to either an experimental group (n = 16) receiving the IMI or an active control group (n = 16). The number of therapeutic appointments was held constant across conditions to account for unspecific treatment effects. The primary outcome was SAD severity, obtained at baseline, interim, post-treatment, and follow-up assessments. The secondary outcome remission was evaluated through a diagnostic interview at follow-up. The trial was registered with ISRCTN (ID: ISRCTN18013983).

RESULTS

Regarding the differential effectiveness between the active control condition and the IMI, two different results were found: There was a higher remission rate in the experimental group compared to the control group, while no significant differences in SAD severity were found.

CONCLUSION

While SAD severity showed a comparable reduction in both groups, significantly fewer patients in the experimental group were still diagnosed with SAD at follow-up. This suggested a difference between self-report and clinical evaluation. Despite the mixed results, IMIs provide a low-barrier intervention and could be used to increase access to therapy and reduce waiting times.

Efficacy of exposure scenario in virtual reality for the treatment of acrophobia: A randomized controlled trial

BACKGROUND AND OBJECTIVES

Individuals with acrophobia (fear of heights) can experience severe anxiety or panic attacks when they are located at height. This randomized controlled study aimed to verify the effects of a novel scalable virtual reality-based exposure (VR exposure) tool in individuals with acrophobia, by exposing them to a predefined set of situations they usually tend to avoid.

METHODS

Forty-three adults were randomly assigned to one of the two groups: the experimental group or the waitlist group. Both groups attended initial short online education. The experimental group consecutively attended three VR-based exposure therapy (VRET) intervention sessions over 3-5 weeks during which the therapist encouraged participants to enter the predefined feared situations, while the control group on the waitlist had no additional intervention.

RESULTS

The findings show that a 3-session VR exposure intervention with a standardized set of tasks effectively reduces the level of experienced height intolerance and particularly avoidance behavior compared to the control waitlist group limited to psychoeducation only. Results were maintained at the 2 months follow-up. The higher the sense of presence after the VR exposure was, the lower the avoidance level rated in the follow-up.

LIMITATIONS

Our study has some limitations, such as potential sample selection bias and tracking of only medium-term effects in the 2-month follow-up.

CONCLUSIONS

The findings show that three sessions of VR exposure intervention with a standardized set of VR-based scenarios are effective in reducing the level of height intolerance and associated avoidance behavior and led to improvement of the outcome measures two months after the procedure. The role of presence was implicated in the prolonged outcome of the VR exposure intervention.

Smartphone apps for mental health: systematic review of the literature and five recommendations for clinical translation

OBJECTIVES

Providing adequate access to mental health services is a global challenge. Smartphone apps offer a potentially cost-effective, available and accessible solution for monitoring, supporting and treating mental health conditions. This systematic review describes and evaluates the usage of smartphone apps across a wide range of mental health disorders in terms of clinical effectiveness, feasibility and acceptability.

DESIGN

This is a systematic review of studies examining treatment, self-monitoring and multipurpose smartphone apps for mental health disorders.

DATA SOURCES

Studies were identified through a comprehensive search of the Ovid and PubMed databases. Articles published up to 14 January 2024 were included based on predefined criteria.

ELIGIBILITY CRITERIA

We included randomised controlled trials that compared mental health apps (single- or multipurpose) with treatment-as-usual or no treatment for clinical populations with mental health disorders. Studies were excluded if they focused on web-based interventions, combined apps with non-TAU treatments or targeted physical health apps.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened and selected studies, with a third reviewer resolving inconsistencies. Extracted data included study details, participant characteristics, app information and outcome measures related to effectiveness, feasibility and acceptability. A risk-of-bias assessment for each study was conducted.

RESULTS

Out of 4153 non-duplicate articles screened, 31 studies met full-text eligibility criteria. These included 6 studies on treatment apps, 4 on self-monitoring apps and 21 on multipurpose apps for a range of mental health disorders. Fifteen were identified as having between some and high concern on the risk-of-bias assessment. While smartphone apps were generally effective and acceptable, their feasibility appeared to decline over time.

CONCLUSIONS

Smartphone apps are promising tools for mental healthcare, demonstrating effectiveness and acceptability. However, challenges such as reduced feasibility over time, potential biases and underrepresented demographics require further research. This review proposes five recommendations for improving clinical translation in future studies.

Systematic review and meta-analysis of adverse events in clinical trials of mental health apps

Mental health apps are efficacious, yet they may pose risks in some. This review (CRD42024506486) examined adverse events (AEs) from mental health apps. We searched (May 2024) the Medline, PsycINFO, Web of Science, and ProQuest databases to identify clinical trials of mental health apps. The risk of bias was assessed using the Cochrane Risk of Bias tool. Only 55 of 171 identified clinical trials reported AEs. AEs were more likely to be reported in trials sampling schizophrenia and delivering apps with symptom monitoring technology. The meta-analytic deterioration rate from 13 app conditions was 6.7% (95% CI = 4.3, 10.1, I2 = 75%). Deterioration rates did not differ between app and control groups (OR = 0.79, 95% CI = 0.62-1.01, I2 = 0%). Reporting of AEs was heterogeneous, in terms of assessments used, events recorded, and detail provided. Overall, few clinical trials of mental health apps report AEs. Those that do often provide insufficient information to properly judge risks related to app use.

Technological Advances in Treating Anxiety Disorders

There has been tremendous interest in utilizing digital interventions to assist in the treatment of anxiety disorders. Anxiety disorders are widely prevalent and often characterized by avoidance, intolerance of uncertainty, interpersonal concerns, and worry. Digital mental health interventions, given their flexibility, may be particularly suited to this population. The authors review the literature on the use of videoconference, virtual reality, website self-help, and mobile applications in the treatment of anxiety disorders. Empirical evidence, advantages, and disadvantages of each format are considered. Additionally, we identify clinical and social challenges unique to the use of these technologies for intervention purposes.

Augmenting self-guided virtual-reality exposure therapy for social anxiety with biofeedback: a randomised controlled trial

Introduction

We previously found that self-guided Virtual Reality Exposure Therapy (VRET) improved Public Speaking Anxiety (PSA) and reduced heartrate. Elevated heartrate characterises social anxiety and the self-guided VRET seemed to reduce heartrate. Thus, receiving continuous biofeedback about physiological arousal during the VRET could help socially anxious individuals to manage their anxiety. The present study aimed to determine whether biofeedback enhances the responsiveness of VRET.

Methods

Seventy-two individuals with high self-reported social anxiety were randomly allocated to VRET-plus-biofeedback (n=38; 25 completers) or VRET alone (n=35; 25 completers). Three hour-long VRET sessions were delivered over three consecutive weeks. During each session, participants delivered a 20-minute public speech in front of a virtual audience. Participants in the VRET-plus-biofeedback group received biofeedback on heartrate and frontal alpha asymmetry (FAA) within the virtual environment and were asked to lower their arousal accordingly. Participants in both groups completed psychometric assessments of social anxiety after each session and at one-month follow-up.

Results

PSA improved by the end of treatment and overall social anxiety improved one month after the VRET across both groups. The VRET-plus-biofeedback group showed a steadier reduction in FAA in the first VRET session and a greater reduction in self-reported arousal across the three sessions than the VRET-alone group.

Conclusion

Biofeedback can steady physiological arousal and lower perceived arousal during exposure. The benefits of self-guided VRET for social anxiety are sustained one month after therapy.

Effects of a digital self-efficacy training in stressed university students: A randomized controlled trial

OBJECTIVE

Self-efficacy is associated with positive mental health outcomes. We developed and tested a digital self-efficacy training for daily recall of autobiographical self-efficacy memories (e.g., memories of successfully overcoming a personal challenge).

METHOD

In this randomized controlled trial, we investigated the effects of the week-long digital self-efficacy training on key mental health outcomes, including anxiety, stress, and hopelessness, and on self-efficacy in 93 university students (mean age 23.3 years, SD: 3.49) with elevated self-reported stress levels. Participants completed either the self-efficacy training combined with ecological momentary assessment (EMA) (training group) or EMA only (control group).

RESULTS

We found significantly reduced hopelessness and trait anxiety in the training group compared to the control group at post-assessment (one day post intervention). Effects on ratings of self-efficacy at post-assessment were also significant when controlling for baseline self-efficacy.

CONCLUSIONS

This stand-alone digital self-efficacy training was significantly associated with a number of positive effects on outcomes compared to a control condition, including reduced hopelessness, trait anxiety, and increased self-efficacy. Future work is needed to replicate and investigate the long-term effects of the training and explore its implementation in clinical populations.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05617248.

DigiDOP: A framework for applying digital technology to the Differential Outcomes Procedure (DOP) for cognitive interventions in persons with neurocognitive disorders

We present a framework -Digi-DOP- that includes a series of evidence-based recommendations to design and apply cognitive interventions for people with Neurocognitive Disorders (NCDs) using a relatively new approach, the Differential Outcomes Procedure (DOP). To do so, we critically review the substantial experimental research conducted with relevant clinical and non-clinical populations, and the theoretical underpinnings of this procedure. We further discuss how existing digital technologies that have been used for cognitive interventions could be applied to overcome some of the limitations of DOP-based interventions and further enhance DOP benefits. Specifically, we present three digital DOP developments that are currently being designed, investigated and/or tested. Finally, we discuss constraints, ethical and legal considerations that need to be taken into account to ensure that the use of technology in DOP-based interventions proposed here does not widen disparities and inequalities. We hope that this framework will inform and guide digital health leaders and developers, researchers and healthcare professionals to design and apply DOP-based interventions for people with NCDs.

Effectiveness of technology-assisted vs face-to-face cognitive behavioural therapy for anxiety and depression in children and young people: A systematic review and meta-analysis

BACKGROUND

Cognitive Behavioural Therapy (CBT) has been proven to be effective for anxiety and depression in children and young people (CYP). Over the past 20 years there have been several attempts at delivering CBT through apps, online software, videogames, but also with a therapist via phone or videoconferencing platforms, with promising results for the "technology-assisted" versions. However, most research, have compared online CBT to waiting lists, and not many studies looked at the effectiveness of face-to-face (f2f) CBT versus technology-assisted CBT.

METHODS

Adopting the PRISMA guidelines, we evaluated 1849 citations and identified 10 eligible studies. Studies were identified through the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, PubMed/MEDLINE, Web of Science, and Scopus.

RESULTS

Ten studies met our inclusion criteria. The studies included a variety of technology-assisted forms of CBT, including videoconferencing and online CBT. Of these, seven looked at the effectiveness of technology-assisted CBT for anxiety in CYP, and seven looked at depression. The meta-analyses had low heterogeneity and showed that technology-assisted CBT was non-inferior to f2f CBT for anxiety and depression in CYP (d = 0.06 and 0.12 respectively).

CONCLUSIONS

Technology-assisted CBT may be a valid alternative for the treatment of anxiety and depression in CYP. Future studies should consider what specific delivery modalities are most cost-effective.

Impact of Group Reality Therapy on Treatment Adherence and Health Indicators in Patients with Type 2 Diabetes Mellitus: A Randomized Controlled Trial

Background: The use of non-pharmacological therapies is important in reducing the complications and consequences of diabetes. Objectives: This study aimed to determine the effect of group reality therapy on adherence to treatment regimens and health indicators in patients with type 2 diabetes. Methods: This randomized controlled trial was performed on 60 patients with diabetes who were referred to Amir Al-Momenin Hospital in Ahvaz. Patients were randomly assigned to either the intervention group (N = 30) or the control group (N = 30). Both groups completed health indicator tests, questionnaires on demographic and clinical information, perceived adherence to the treatment regimen, and the Perceived Stress Scale. The intervention group received reality therapy training, which consisted of 10 sessions of 45 minutes each (one session per week) over 2 months, delivered through lectures and face-to-face training sessions. The control group received only routine hospital interventions. The collected data were then analyzed using a one-way t-test and one-way analysis of variance (ANOVA). Results: Twenty-seven patients in the intervention group and 27 in the control group completed the study. After analyzing the data, it was revealed that the mean age of the patients in the control group was 55.30 ± 7.95, while it was 51.96 ± 10.55 in the intervention group. Findings showed that scores for the dimensions of adherence to the treatment regimen in the intervention group significantly increased compared to the control group (P < 0.001). Additionally, the mean health indicators in the intervention group showed a significant decrease compared to the control group (P < 0.001). Moreover, the mean blood sugar level of patients in the intervention group decreased from 229.63 ± 98.76 to 123.59 ± 42.03. Likewise, the level of glycosylated hemoglobin and blood cholesterol significantly decreased from 8.19 ± 2.09 to 6.11 ± 1.86 and from 176.52 ± 51.53 to 146.22 ± 34.68, respectively. Conclusions: A reality therapy training program can be effectively used to increase treatment adherence and improve health indicators in patients with type 2 diabetes.

Extended Reality for Mental Health Evaluation: Scoping Review

BACKGROUND

Mental health disorders are the leading cause of health-related problems worldwide. It is projected that mental health disorders will be the leading cause of morbidity among adults as the incidence rates of anxiety and depression grow worldwide. Recently, "extended reality" (XR), a general term covering virtual reality (VR), augmented reality (AR), and mixed reality (MR), is paving the way for the delivery of mental health care.

OBJECTIVE

We aimed to investigate the adoption and implementation of XR technology used in interventions for mental disorders and to provide statistical analyses of the design, usage, and effectiveness of XR technology for mental health interventions with a worldwide demographic focus.

METHODS

In this paper, we conducted a scoping review of the development and application of XR in the area of mental disorders. We performed a database search to identify relevant studies indexed in Google Scholar, PubMed, and the ACM Digital Library. A search period between August 2016 and December 2023 was defined to select papers related to the usage of VR, AR, and MR in a mental health context. The database search was performed with predefined queries, and a total of 831 papers were identified. Ten papers were identified through professional recommendation. Inclusion and exclusion criteria were designed and applied to ensure that only relevant studies were included in the literature review.

RESULTS

We identified a total of 85 studies from 27 countries worldwide that used different types of VR, AR, and MR techniques for managing 14 types of mental disorders. By performing data analysis, we found that most of the studies focused on high-income countries, such as the United States (n=14, 16.47%) and Germany (n=12, 14.12%). None of the studies were for African countries. The majority of papers reported that XR techniques lead to a significant reduction in symptoms of anxiety or depression. The majority of studies were published in 2021 (n=26, 30.59%). This could indicate that mental disorder intervention received higher attention when COVID-19 emerged. Most studies (n=65, 76.47%) focused on a population in the age range of 18-65 years, while few studies (n=2, 3.35%) focused on teenagers (ie, subjects in the age range of 10-19 years). In addition, more studies were conducted experimentally (n=67, 78.82%) rather than by using analytical and modeling approaches (n=8, 9.41%). This shows that there is a rapid development of XR technology for mental health care. Furthermore, these studies showed that XR technology can effectively be used for evaluating mental disorders in a similar or better way that conventional approaches.

CONCLUSIONS

In this scoping review, we studied the adoption and implementation of XR technology for mental disorder care. Our review shows that XR treatment yields high patient satisfaction, and follow-up assessments show significant improvement with large effect sizes. Moreover, the studies adopted unique designs that were set up to record and analyze the symptoms reported by their participants. This review may aid future research and development of various XR mechanisms for differentiated mental disorder procedures.

Efficacy of tDCS to enhance virtual reality exposure therapy response in acrophobia: A randomized controlled trial

[BACKGROUND]: Virtual reality exposure therapy (VRET) has been recognized as an effective treatment for specific phobias and has the potential to overcome the limitations of traditional exposure therapy. The pursuit of non-invasive brain stimulation provides a practical means of augmenting VRET. Transcranial direct current stimulation (tDCS), a non-invasive neuromodulation technique, stimulates the medial prefrontal cortex (mPFC), with the potential to enhance the effects of exposure therapy. Therefore, we conducted a randomized controlled trial to examine whether tDCS enhanced the effects of VRET in acrophobia. [METHOD]: This study recruited 64 college students with significant fear of height (based on the Acrophobia Questionnaire, AQ). Finally, 61 participants were randomly allocated to the tDCS active-stimulated group (n = 30) or the sham-stimulated group (n = 31). After stimulation, VRET was conducted, and clinical indices were recorded. The AQ was used as the first primary outcome, and Subjective Units of Distress (SUDS) and the Heights Interpretation Questionnaire (HIQ) were used as secondary outcomes. [RESULT]: There was a significant reduction in psychometric and behavioral anxiety measurements from pre to post treatment as indicated by main effects for the factor time (AQ-Anxiety: F (2.60) = 139.55, p < 0.001, η2 = 0.83; AQ-Avoidance: F (2.60) = 53.73, p < 0.001, η2 = 0.69; HIQ: F (2.60) = 128.12, p < 0.001, η2 = 0.81; STAI-Y-S: F (2.60) = 15.44, p < 0.001, η2 = 0.34; BAI: F (2.60) = 73.81, p < 0.001, η2 = 0.71). Compared with the sham-stimulated group, the reduction of AQ-Anxiety and SUDS in the first exposure trial (F (2,60) = 8.56, p = 0.001, η2 = 0.23; t = 2.34, p = 0.024, d = 0.61) was significantly faster in the active group. At follow-up, there was also a further reduction in AQ anxiety and avoidance (Anxiety: M = 56.51 ± 27.19; main effect time F (1,60) = 25.16, p < 0.001, η2 = 0.35; Avoidance: M = 12.57 ± 7.97; main effect time F (1,60) = 31.40, p < 0.001, η2 = 0.45) without interaction time*group (Anxiety: F (1.60) = 0.12, p = 0.740, η2 = 0.00; Avoidance: F (1.60) = 0.64, p = 0.430, η2 = 0.02). [CONCLUSION]: Results could be explained tDCS could accelerate the effects of VRET on acrophobia by stimulating mPFC, indicating that tDCS may be used as an enhancement technique for exposure therapy for specific phobias.

Impact of virtual reality applications in the treatment of anxiety disorders: A systematic review and meta-analysis of randomized-controlled trials

BACKGROUND AND OBJECTIVES

Anxiety disorders are the most prevalent mental disorders worldwide. Virtual reality (VR) treatment approaches have increasingly been studied. Before clinical implementation, it is necessary to evaluate the treatment effect of VR applications. The objective is to evaluate the treatment effect of virtual reality applications in the treatment of anxiety disorders compared to conventional therapy.

METHODS

A systematic literature review with meta-analysis was conducted. Four databases were used to identify randomized controlled trials published between April 2011 and April 2021 which compare VR applications with non-VR interventions or waiting lists. Study characteristics, pre- and post-treatment data were extracted. Hedges g was calculated as effect size. Primary outcome was anxiety symptoms.

RESULTS

Data from 17 studies from 827 participants was extracted. The studies examined specific phobia (n = 9), social anxiety disorder (n = 4), agoraphobia (n = 2) and panic disorder (n = 2). 16 out of 17 studies used head-mounted displays as VR application. A non-significant effect size with significant heterogeneity was observed in favor of the use of VR applications in anxiety symptoms (g, 0.33; 95%-CI, -0.20-0.87). Compared to passive control groups, VR applications are associated significant with lower anxiety symptoms (g, 1.29; 95%-CI, 0.68-1.90).

LIMITATIONS

The study and patient characteristics varied between the individual studies which is reflected in a high statistical heterogeneity of the effect sizes.

CONCLUSIONS

The added value of VR applications over waiting-list or psychoeducation only control groups is obvious. VR applications can be used as part of the treatment of anxiety disorders, especially when conventional therapy is unavailable.

Virtual reality interventions for the treatment of anxiety disorders: A scoping review

BACKGROUND

& Objectives: Virtual Reality (VR) refers to an artificial, immersive three-dimensional environment with interactive sensory stimuli. VR is typically incorporated into the psychotherapeutic process as a means of providing exposure therapy. The objectives of this scoping review were to synthesize the most up-to-date evidence on the outcomes, acceptability, and side effects of VR interventions for treating anxiety disorders in adults.

METHODS

This scoping review is grounded in the methodological framework of Arksey and O'Malley (2005). The databases searched were PubMed, EMBASE, Web of Science, PsycINFO, and ProQuest Dissertations and Theses.

RESULTS

The search process identified 112 unique citations. 52 (46%) of the eligible articles examined participants with specific phobias, 25 (22%) with PTSD, 21 (19%) with social anxiety disorder, 12 (10%) with panic disorder with or without agoraphobia, and 3 (3%) with generalized anxiety disorder. VR interventions often led to statistically significant and meaningful reductions in symptoms for people with anxiety disorders. Additionally, they were acceptable to clients and associated with minimal side effects for all types of anxiety disorders, except for Combat-Related PTSD in Vietnam veterans.

LIMITATIONS

Limitations included the fact that the studies in this review were of varying quality, and that articles in languages other than English and French were excluded.

CONCLUSION

VR interventions appeared to be a viable alternative to conventional exposure therapy. Future research should include more male participants and have a stronger emphasis on acceptability and side effects. Increased traction for VR interventions for generalized anxiety disorder and panic disorder is also important.

Exploring Women's State-Level Anxiety in Response to Virtual Reality Erotica

Virtual Reality (VR)-based treatments for anxiety disorders are efficacious but there is a lack of research examining anxious responses to VR erotica, which could innovate treatments for sexual difficulties. We examined erotica features that elicited anxiety and sexual presence in women. Thirty-eight women viewed erotic videos from different modalities (2D, VR) and points of view (1st, 3rd person) and completed anxiety and sexual presence measures before and after each video. Women experienced greater anxiety for VR than 2D films and reported the most anxiety for VR 1st person films. Sexual presence was affected by modality and point of view.

Individualized Virtual Reality for Increasing Self-Compassion: Evaluation Study

BACKGROUND

Depression and anxiety are common and debilitating mental disorders with severe negative repercussions at both individual and societal levels. Although virtual reality (VR) has emerged as a safe and effective tool for the treatment of anxiety disorders, studies of the therapeutic application of VR to treat depression are more limited.

OBJECTIVE

The purpose of this study was to test whether a novel type of individualized VR (iVR) can be used to improve self-compassion and decrease depressive symptoms and to evaluate the usability and acceptability of this approach, as rated by participants. The iVR system was designed and developed based on the feedback obtained from a previous study, with improved appearance and feel of the avatar and enhanced graphical quality.

METHODS

A total of 36 young adult participants were recruited from a university community social media site. Participants were aware that the study was investigating a treatment for depression but were not recruited based on depression diagnosis. Participants were asked to complete 2 iVR sessions, spaced 2 weeks apart. At baseline and upon completion of each iVR session, participants were asked to complete validated measures of self-compassion and depression. Upon completion of both iVR sessions, additional measures were administered to assess participants' perceptions about the perceived usability and system acceptability of the iVR approach.

RESULTS

Self-compassion was assessed at the beginning of session 1 (preintervention baseline) and at the end of session 1 (postintervention assessment). Owing to COVID-19 constraints, 36% (13/36) of the participants were unable to complete the follow-up iVR session. Self-compassion was assessed again for the remaining 64% (23/36) of the participants at the end of session 2 (postintervention assessment). Within-group analyses revealed that self-compassion was significantly increased at the end of both session 1 (P=.01) and session 2 (P=.03) relative to baseline. There was also a nonsignificant trend for depressive symptoms to be low at the end of session 2 relative to baseline. Both quantitative and qualitative participant data supported the iVR approach as being acceptable and usable.

CONCLUSIONS

Although these data must be treated as preliminary owing to the small sample size and potential selection bias, the data provide encouraging initial evidence that iVR might be a useful tool to enhance self-compassion and reduce depressive symptoms, highlighting the need for randomized controlled trials in the future.

Automated mobile virtual reality cognitive behavior therapy for aviophobia in a natural setting: a randomized controlled trial

BACKGROUND

Access to evidence-based psychological treatment is a challenge worldwide. We assessed the effectiveness of a fully automated aviophobia smartphone app treatment delivered in combination with a $5 virtual reality (VR) viewer.

METHODS

In total, 153 participants from the Dutch general population with aviophobia symptoms and smartphone access were randomized in a single-blind randomized controlled trial to either an automated VR cognitive behavior therapy (VR-CBT) app treatment condition (n = 77) or a wait-list control condition (n = 76). The VR-CBT app was delivered over a 6-week period in the participants' natural environment. Online self-report assessments were completed at baseline, post-treatment, at 3-month and at 12-month follow-up. The primary outcome measure was the Flight Anxiety Situations Questionnaire (FAS). Analyses were based on intent-to-treat.

RESULTS

A significant reduction of aviophobia symptoms at post-test for the VR-CBT app compared with the control condition [p < 0.001; d = 0. 98 (95% CI 0.65-1.32)] was demonstrated. The dropout rate was 21%. Results were maintained at 3-month follow-up [within-group d = 1.14 (95% CI 0.46-1.81)] and at 12-month follow-up [within-group d = 1.12 (95% CI 0.46-1.79)]. Six participants reported adverse effects of cyber sickness symptoms.

CONCLUSIONS

This study is the first to show that fully automated mobile VR-CBT therapy delivered in a natural setting can maintain long-term effectiveness in reducing aviophobia symptoms. In doing so, it offers an accessible and scalable evidence-based treatment solution that can be applied globally at a fraction of the cost of current treatment alternatives.

Selecting and describing control conditions in mobile health randomized controlled trials: a proposed typology

Hundreds of randomized controlled trials (RCTs) have tested the efficacy of mobile health (mHealth) tools for a wide range of mental and behavioral health outcomes. These RCTs have used a variety of control condition types which dramatically influence the scientific inferences that can be drawn from a given study. Unfortunately, nomenclature across mHealth RCTs is inconsistent and meta-analyses commonly combine control conditions that differ in potentially important ways. We propose a typology of control condition types in mHealth RCTs. We define 11 control condition types, discuss key dimensions on which they differ, provide a decision tree for selecting and identifying types, and describe the scientific inferences each comparison allows. We propose a five-tier comparison strength gradation along with four simplified categorization schemes. Lastly, we discuss unresolved definitional, ethical, and meta-analytic issues related to the categorization of control conditions in mHealth RCTs.

Virtual reality (VR) therapy for patients with psychosis: satisfaction and side effects

BACKGROUND

Automated virtual reality therapies are being developed to increase access to psychological interventions. We assessed the experience with one such therapy of patients diagnosed with psychosis, including satisfaction, side effects, and positive experiences of access to the technology. We tested whether side effects affected therapy.

METHODS

In a clinical trial 122 patients diagnosed with psychosis completed baseline measures of psychiatric symptoms, received gameChange VR therapy, and then completed a satisfaction questionnaire, the Oxford-VR Side Effects Checklist, and outcome measures.

RESULTS

79 (65.8%) patients were very satisfied with VR therapy, 37 (30.8%) were mostly satisfied, 3 (2.5%) were indifferent/mildly dissatisfied, and 1 (0.8%) person was quite dissatisfied. The most common side effects were: difficulties concentrating because of thinking about what might be happening in the room (n = 17, 14.2%); lasting headache (n = 10, 8.3%); and the headset causing feelings of panic (n = 9, 7.4%). Side effects formed three factors: difficulties concentrating when wearing a headset, feelings of panic using VR, and worries following VR. The occurrence of side effects was not associated with number of VR sessions, therapy outcomes, or psychiatric symptoms. Difficulties concentrating in VR were associated with slightly lower satisfaction. VR therapy provision and engagement made patients feel: proud (n = 99, 81.8%); valued (n = 97, 80.2%); and optimistic (n = 96, 79.3%).

CONCLUSIONS

Patients with psychosis were generally very positive towards the VR therapy, valued having the opportunity to try the technology, and experienced few adverse effects. Side effects did not significantly impact VR therapy. Patient experience of VR is likely to facilitate widespread adoption.

oVRcome - Self-guided virtual reality for specific phobias: A randomised controlled trial

OBJECTIVE

Mobile health applications for mental health are widely accessible but most have had limited research evaluation. Virtual reality exposure therapy is an emerging treatment for specific phobias. Most virtual reality studies have investigated high-end virtual reality devices, typically only available in research and limited clinical settings for a single phobia. This study evaluated the effectiveness of oVRcome, a mobile health application combining self-guided virtual reality exposure and cognitive behaviour therapy, for five specific phobias.

METHODS

This is a 2-arm 6-week randomised controlled trial, with a waitlist control group and follow-up at week 12. Participants were required to live in New Zealand; be aged 18-64 years; have a fear of flying, heights, spiders, dogs and needles; score above 4 on the Brief Standard Self-rating scale for phobic patients; and have access to a smartphone and Internet. oVRcome consists of six modules of psychoeducation, relaxation, mindfulness, cognitive techniques, exposure through virtual reality and relapse prevention over 6 weeks. The primary outcome was the change from baseline to week 6 on the Severity Measures for Specific Phobia - Adults. All analyses were performed on intention-to-treat set.

RESULTS

A total of 126 participants were randomised, and 109 completed the follow-up at week 6, for a retention rate of 86.5%. The mean change in Severity Measures for Specific Phobia - Adults score from baseline to week 6 was greater in the active group compared with the waitlist group (active group -20.53 [standard deviation = 8.24]; waitlist group: - 12.31 [standard deviation = 10.66]; p < 0.001). The effect size for this difference was 0.86.

CONCLUSION

Self-guided use of the oVRcome app was effective at reducing severity of specific phobia symptoms in a sample of people with a self-reported fear of flying, heights, spiders, dogs or needles.Trial registry clinicaltrials.gov NCT04909177.

Conversational Agent Interventions for Mental Health Problems: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Mental health problems are a crucial global public health concern. Owing to their cost-effectiveness and accessibility, conversational agent interventions (CAIs) are promising in the field of mental health care.

OBJECTIVE

This study aims to present a thorough summary of the traits of CAIs available for a range of mental health problems, find evidence of efficacy, and analyze the statistically significant moderators of efficacy via a meta-analysis of randomized controlled trial.

METHODS

Web-based databases (Embase, MEDLINE, PsycINFO, CINAHL, Web of Science, and Cochrane) were systematically searched dated from the establishment of the database to October 30, 2021, and updated to May 1, 2022. Randomized controlled trials comparing CAIs with any other type of control condition in improving depressive symptoms, generalized anxiety symptoms, specific anxiety symptoms, quality of life or well-being, general distress, stress, mental disorder symptoms, psychosomatic disease symptoms, and positive and negative affect were considered eligible. This study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Data were extracted by 2 independent reviewers, checked by a third reviewer, and pooled using both random effect models and fixed effects models. Hedges g was chosen as the effect size.

RESULTS

Of the 6900 identified records, a total of 32 studies were included, involving 6089 participants. CAIs showed statistically significant short-term effects compared with control conditions in improving depressive symptoms (g=0.29, 95% CI 0.20-0.38), generalized anxiety symptoms (g=0.29, 95% CI 0.21-0.36), specific anxiety symptoms (g=0.47, 95% CI 0.07-0.86), quality of life or well-being (g=0.27, 95% CI 0.16-0.39), general distress (g=0.33, 95% CI 0.20-0.45), stress (g=0.24, 95% CI 0.08-0.41), mental disorder symptoms (g=0.36, 95% CI 0.17-0.54), psychosomatic disease symptoms (g=0.62, 95% CI 0.14-1.11), and negative affect (g=0.28, 95% CI 0.05-0.51). However, the long-term effects of CAIs for the most mental health outcomes were not statistically significant (g=-0.04 to 0.39). Personalization and empathic response were 2 critical facilitators of efficacy. The longer duration of interaction with conversational agents was associated with the larger pooled effect sizes.

CONCLUSIONS

The findings show that CAIs are research-proven interventions that ought to be implemented more widely in mental health care. CAIs are effective and easily acceptable for those with mental health problems. The clinical application of this novel digital technology will conserve human health resources and optimize the allocation of mental health services.

TRIAL REGISTRATION

PROSPERO CRD42022350130; https://tinyurl.com/mvhk6w9p.

Using the Theoretical Domains Framework to Inform the Implementation of Therapeutic Virtual Reality into Mental Healthcare

Evidence supporting the efficacy of therapeutic virtual reality (VR) for mental health conditions is rapidly growing. However, little is known about how best to implement VR, or the challenges perceived by treatment providers. This study aimed to (1) synthesis perspectives of staff working in private mental healthcare and (2) use the Theoretical Domains Framework (TDF) and Behaviour Change Wheel (BCW) to identify mechanisms of change targets and intervention functions to facilitate its clinical implementation. Semi-structured interviews were conducted with clinicians (n = 14) and service managers (n = 5) working in a major private mental health hospital in Victoria, Australia. Transcripts were coded using framework analysis to identify relevant TDF domains. Specific belief statements were generated and coded as a barrier and/or facilitator and thematically organised within domains. Domains were ranked for importance based on frequency, elaboration, and evidence of conflicting beliefs. Using the BCW, domains were mapped to their respective COM-B components and indicated intervention functions. A total of 11 TDF domains were identified as relevant to early-stage implementation of therapeutic VR. Three domains were judged as highly important (beliefs about consequences; environmental context and resources; knowledge), while seven domains were judged as moderately important (social/professional role and identity; emotions; skills; memory, attention, and decision processes; intentions; beliefs about capabilities; social influences). Based on current data, we propose a theory-informed roadmap to promote VR uptake in mental healthcare services. A priority for intervention development should be addressing knowledge gaps and attitudinal barriers (e.g., safety concerns) with education and training.

An internet-based self-applied rat phobia treatment using a Virtual Therapy Assistant: Study protocol for a randomized controlled trial

Specific phobias are a common anxiety disorder that deteriorates the lives of people who suffer from them. To reduce the symptoms produced by this mental disorder exposure therapies have been used. However, low- and middle-income countries, including Mexico, have the lowest rate of treatment due to multiple barriers that prevent addressing mental health problems. Self-applied treatments have been explored in previous studies, nevertheless, high dropout rates are a common problem in this kind of treatment. An alternative is using immersive self-applied treatments that could help increase adherence to the treatment. This article aims to present a study protocol to explore the feasibility of an Internet self-applied exposure treatment for rat phobias, using four types of immersive multimedia elements: images, videos, video games, and 360° videos. Also, the satisfaction and perception of a Virtual Therapy Assistant (VTA) that provides information and support to the user are described. The study protocol will compare two groups of participants, one on the waiting list, and the other will receive the self-applied treatment for rat phobia supported by the VTA. For this study, 45 participants will be recruited and the evaluation measures will be taken at four different times: baseline, post-treatment, and follow-ups at 3 and 6 months. The levels of anxiety and avoidance of the user manifested during the exposure to the multimedia elements, the improvement of the user's clinical symptoms, the level of satisfaction, the perception of effectiveness, and ease of use of the self-applied system will be evaluated. This study is expected to support the viability of self-applied treatment for rat phobias and the use of a VTA, showing the impact on treatment adherence. To the best of our knowledge, this is the first study to explore an exposure treatment for rats using different multimedia elements with the support of a VTA. The work will serve as a basis for the development of new virtual assistants that help in the treatment of other types of specific phobias. This research has been registered in Clinical Trials NCT (NCT05081323).

An exploratory analysis of the effect size of the mobile mental health Application, mindLAMP

Objectives

Despite the proliferation of mobile mental health apps, evidence of their efficacy around anxiety or depression is inadequate as most studies lack appropriate control groups. Given that apps are designed to be scalable and reusable tools, insights concerning their efficacy can also be assessed uniquely through comparing different implementations of the same app. This exploratory analysis investigates the potential to report a preliminary effect size of an open-source smartphone mental health app, mindLAMP, on the reduction of anxiety and depression symptoms by comparing a control implementation of the app focused on self-assessment to an intervention implementation of the same app focused on CBT skills.

Methods

A total of 328 participants were eligible and completed the study under the control implementation and 156 completed the study under the intervention implementation of the mindLAMP app. Both use cases offered access to the same in-app self-assessments and therapeutic interventions. Multiple imputations were utilized to impute the missing Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 survey scores of the control implementation.

Results

Post hoc analysis revealed small effect sizes of Hedge's g = 0.34 for Generalized Anxiety Disorder-7 and Hedge's g = 0.21 for Patient Health Questionnaire-9 between the two groups.

Conclusions

mindLAMP shows promising results in improving anxiety and depression outcomes in participants. Though our results mirror the current literature in assessing mental health apps' efficacy, they remain preliminary and will be used to inform a larger, well-powered study to further elucidate the efficacy of mindLAMP.

Cognition, criminal conduct, and virtual reality: Understanding and reducing offending using simulated environments

Over the past years, research has shown that virtual reality (VR) technology can be used to observe, interpret, and change human behavior and cognition in a variety of domains. This chapter explores the potential of VR as a tool to observe, interpret, and change human behavior and cognition as they relate to antisocial behavior. We review the criminological research literature as well as research literature from related disciplines on VR applications that has focused on observing and reducing antisocial behavior. The main findings of our review suggest that the key merits of VR in the domain of crime and antisocial behavior are its ability to provide safe learning environments that would otherwise involve risk, the possibility of generating ethical and ecologically valid virtual alternatives for real-life situations, and the development of stimuli that are impossible to create in real life. These unique characteristics make VR a promising tool to observe criminal behavior as it takes place and develop intervention programs to reduce antisocial behavior.

Virtual reality in the diagnostic and therapy for mental disorders: A systematic review

BACKGROUND

Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders.

OBJECTIVE

To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders.

DATA SOURCE

Systematic literature searches via PubMed (last literature update: 9^th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders.

ELIGIBILITY CRITERIA

To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology.

STUDY EVALUATION

For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria.

RESULTS

Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder.

CONCLUSION

While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application.

REVIEW REGISTRATION

PROSPERO register CRD42020188436.

FUNDING

The review was funded by budgets from the University of Bonn. No third party funding was involved.

Extended reality for mental health: Current trends and future challenges

Virtual and augmented reality have been used to diagnose and treat several mental health disorders for decades. Technological advances in these fields have facilitated the availability of commercial solutions for end customers and practitioners. However, there are still some barriers and limitations that prevent these technologies from being widely used by professionals on a daily basis. In addition, the COVID-19 pandemic has exposed a variety of new scenarios in which these technologies could play an essential role, like providing remote treatment. Disorders that traditionally had received less attention are also getting in the spotlight, such as depression or obsessive-compulsive disorder. Improvements in equipment and hardware, like Mixed Reality Head Mounted Displays, could help open new opportunities in the mental health field. Extended reality (XR) is an umbrella term meant to comprise Virtual reality (VR), mixed reality (MR), and augmented reality (AR). While XR applications are eminently visual, other senses are being explored in literature around multisensory interactions, such as auditory, olfactory, or haptic feedback. Applying such stimuli within XR experiences around mental disorders is still under-explored and could greatly enrich the therapeutic experience. This manuscript reviews recent research regarding the use of XR for mental health scenarios, highlighting trends, and potential applications as well as areas for improvement. It also discusses future challenges and research areas in upcoming topics such as the use of wearables, multisensory, and multimodal interaction. The main goal of this paper is to unpack how these technologies could be applied to XR scenarios for mental health to exploit their full potential and follow the path of other health technologies by promoting personalized medicine.

Estimating the Economic Value of Automated Virtual Reality Cognitive Therapy for Treating Agoraphobic Avoidance in Patients With Psychosis: Findings From the gameChange Randomized Controlled Clinical Trial

BACKGROUND

An automated virtual reality cognitive therapy (gameChange) has demonstrated its effectiveness to treat agoraphobia in patients with psychosis, especially for high or severe anxious avoidance. Its economic value to the health care system is not yet established.

OBJECTIVE

In this study, we aimed to estimate the potential economic value of gameChange for the UK National Health Service (NHS) and establish the maximum cost-effective price per patient.

METHODS

Using data from a randomized controlled trial with 346 patients with psychosis (ISRCTN17308399), we estimated differences in health-related quality of life, health and social care costs, and wider societal costs for patients receiving virtual reality therapy in addition to treatment as usual compared with treatment as usual alone. The maximum cost-effective prices of gameChange were calculated based on UK cost-effectiveness thresholds. The sensitivity of the results to analytical assumptions was tested.

RESULTS

Patients allocated to gameChange reported higher quality-adjusted life years (0.008 QALYs, 95% CI -0.010 to 0.026) and lower NHS and social care costs (-£105, 95% CI -£1135 to £924) compared with treatment as usual (£1=US $1.28); however, these differences were not statistically significant. gameChange was estimated to be worth up to £341 per patient from an NHS and social care (NHS and personal social services) perspective or £1967 per patient from a wider societal perspective. In patients with high or severe anxious avoidance, maximum cost-effective prices rose to £877 and £3073 per patient from an NHS and personal social services perspective and societal perspective, respectively.

CONCLUSIONS

gameChange is a promising, cost-effective intervention for the UK NHS and is particularly valuable for patients with high or severe anxious avoidance. This presents an opportunity to expand cost-effective psychological treatment coverage for a population with significant health needs.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN17308399; https://www.isrctn.com/ISRCTN17308399.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2019-031606.

An adaptation algorithm for personalised virtual reality exposure therapy

BACKGROUND

Anxiety disorders are highly prevalent in mental health problems. The lives of people suffering from an anxiety disorder can be severely impaired. Virtual Reality Exposure Therapy (VRET) is an effective treatment, which immerses patients in a controlled Virtual Environment (VE). This creates the opportunity to confront feared stimuli and learn how to deal with them, which may result in the reduction of anxiety. The configuration of these VEs requires extensive effort to maximise the potential of Virtual Reality (VR) and the effectiveness of the therapy. Manual configuration becomes infeasible when the number of possible virtual stimuli combinations is infinite. Due to the growing complexity, acquiring the skills to truly master a VR system is difficult and it increases the threshold for psychotherapists to use such useful systems. We therefore developed a prototype of a supportive algorithm to facilitate the use of VRET in a clinical setting. This automatised system assists psychotherapists to use the wide range of functionalities without burdening them with technical challenges. Thus, psychotherapists can focus their attention on the patient.

METHODS

In this paper both the prototype of the algorithm and a first proof of concept are described. The algorithm suggests environment configurations for VRET, tailored to the individual therapeutic needs of each patient. The system aims to maximise learning during exposure therapy for different combinations of stimuli by using the Rescorla-Wagner model as a predictor for learning. In a first proof of concept, the VE configurations suggested by the algorithm for three anonymised clinical vignettes were compared with prior manual configurations by two psychotherapists.

RESULTS

The prototype of the algorithm and a first proof of concept are described. The first proof of concept demonstrated the relevance and potential of the proposed system, as it managed to propose similar configurations for the clinical vignettes compared to those made by therapists. Nonetheless, because of the exploratory nature of the study, no claims can yet be made about its efficacy.

CONCLUSIONS

With the increasing ubiquity of immersive technologies, this technology for assisted configuration of VEs could make VRET a valuable tool for psychotherapists.

Automated app-based augmented reality cognitive behavioral therapy for spider phobia: Study protocol for a randomized controlled trial

Background

Fear of spiders, or Arachnophobia, is one of the most common specific phobias. The gold standard treatment, in vivo exposure therapy, is effective, but comes with significant limitations, including restricted availability, high costs, and high refusal rates. Novel technologies, such as augmented reality, may help to overcome these limitations and make Exposure Therapy more accessible by using mobile devices.

Objective

This study will use a Randomized Controlled Trial design to investigate whether ZeroPhobia: Arachnophobia, a 6-week Augmented Reality Exposure Therapy smartphone self-help application, can effectively reduce spider phobia symptoms. Additionally, we will examine user-friendliness of the application and the effect of usage intensity and presence on treatment outcome.

Methods

This study is registered in the Netherlands Trial Registry under NL70238.029.19 (Trial NL9221). Ethical approval was received on October 11, 2019. One-hundred-twelve participants (age 18–64, score ≥ 59) on the Fear of Spiders Questionnaire [FSQ] will be recruited from the general Dutch population and randomly assigned to a treatment or waitlist control group. The ZeroPhobia application can be accessed on users’ smartphone. Baseline, post-test (i.e., at six weeks), 3- and 12-month follow-up assessments will be done, each including the Fear of Spiders Questionnaire as the main outcome measure as well as additional measures of anxiety, depression, user-friendliness, and presence as secondary measures and covariates.

Results

The study was funded on September 25, 2018. Data collection started in September 2021 and the study is expected to run until September 2022.

Conclusions

Our study will improve our understanding of the efficacy and feasibility of providing Exposure Therapy for spider phobia using an Augmented Reality self-help application, with the intention of making mental health care more accessible.

Self-guided virtual reality therapy for social anxiety disorder: a study protocol for a randomized controlled trial

BACKGROUND

Social anxiety disorder (SAD) is a highly prevalent mental disorder associated with enormous stress and suffering. Cognitive behavior therapy (CBT) is the first-line treatment for SAD, yet its accessibility is often constrained with long waiting times. Digital therapeutic applications, including psychoeducation and self-guided behavioral experiments in virtual reality (VR), could facilitate access and reduce waiting times. The study aims to investigate if ultra-short-time therapy involving self-guided digital therapeutic applications with VR components can reduce the severity of SAD.

METHODS

Forty SAD patients will participate in this randomized controlled trial. Half will get access to a self-guided, digital therapeutic application with exposure-based behavioral experiments in VR, while the other half will receive a control treatment. Both treatments include four therapeutic appointments. Changes in the severity of SAD will be measured after each appointment and on a 6-week follow-up assessment and will be compared between groups, with the change in SAD measured at baseline- and post-assessment as primary outcome.

DISCUSSION

Self-guided digital therapeutic applications including ultra-short-time therapy combined with VR could help reduce the waiting time for patients and relieve the health system. The results of this study may inform psychotherapists regarding the potential of self-guided digital therapeutic applications including exposure-based behavioral experiments in VR for SAD and will provide important insight for future research on VR therapy.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN18013983 . Registered on 1 February 2022.

Exploring the Effect of a Nature-based Virtual Reality Environment on Stress in Adolescents

Adolescent mental health is a growing public health issue, with 30% of teens reporting increased stress and 20% of adolescents suffering from depression. Given the scarcity and lack of scalability of mental health services available, the use of self-administered, evidence-based technologies to support adolescent mental health is both timely and imperative. We conducted a mixed-methods pilot study with 31 adolescents ages 14-19 (m = 17.97) to explore the self-administration of a nature-based virtual reality tool. Participant use of the VR environment ranged from 1 to 10 sessions (m = 6.6) at home over a 2-week period while reporting their daily stress and mood levels. All participants completed all of the study protocols, indicating our protocol was feasible and the VR environment engaging. Post-study interviews indicated that most participants found the VR tool to be relaxing and helpful with stress. The themes of Calm Down, Relaxation, and Escape emerged to articulate the participants' experiences using the VR environment. Additionally, participants provided rich data regarding their preferences and activity in the VR environment as well as its effect on their emotional states. Although the sample size was insufficient to determine the impact on depression, we found a significant reduction in momentary stress as a result of using the VR tool. These preliminary data inform our own virtual reality environment design, but also provide evidence of the potential for self-administered virtual reality as a promising tool to support adolescent mental health.

The Symbiosis of Virtual Reality Exposure Therapy and Telemental Health: A Review

Phobias and related anxiety are common and costly mental health disorders. Experts anticipate the prevalence of phobias will increase due to the COVID-19 pandemic. Exposure therapies have been established as effective and reliable treatments for anxiety, including recent innovations in virtual reality-based exposure therapy (VRET). With the recent advent of telemental health (TMH), VRET is poised to become mainstream. The combination of VRET and TMH has the potential to extend provider treatment options and improve patient care experiences. In this narrative review, we describe how recent events have accelerated VRET + TMH, identify barriers to VRET + TMH implementation, and discuss strategies to navigate those barriers.

Virtual Reality Exposure Therapy for Treating Social Anxiety: A Scoping Review of Treatment Designs and Adaptation to Stuttering

Virtual Reality Exposure Therapy (VRET) has been shown to be an effective technique for reducing social anxiety. People who stutter are at greater risk of developing heightened social anxiety. Cognitive behavior therapy protocols have shown promise in reducing social anxiety in people who stutter, but no studies have investigated VRET targeting social anxiety associated with stuttering. The aim of the current review is to provide an overview of VRET techniques used to treat social anxiety and insights into how these techniques might be adopted in the case of comorbid stuttering and social anxiety. Twelve studies were reviewed to understand key distinctions in VRET protocols used to treat social anxiety. Distinctions include exercises targeting public speaking vs. general social anxiety, computer-generated virtual environments vs. 360° video, and therapist guided vs. automated VRET. Based on the review findings, we propose how certain features could be applied in the case of stuttering. Virtual therapists, inhibitory learning techniques and integration into speech therapy may be suitable ways to tailor VRET. Regardless of these different techniques, VRET should consider the situations and cognitive-behavioral processes that underlie the experience of social anxiety amongst people who stutter.

The Effectiveness of Serious Games in Alleviating Anxiety: Systematic Review and Meta-analysis

BACKGROUND

Anxiety is a mental disorder characterized by apprehension, tension, uneasiness, and other related behavioral disturbances. One of the nonpharmacological treatments used for reducing anxiety is serious games, which are games that have a purpose other than entertainment. The effectiveness of serious games in alleviating anxiety has been investigated by several systematic reviews; however, they were limited by design and methodological weaknesses.

OBJECTIVE

This study aims to assess the effectiveness of serious games in alleviating anxiety by summarizing the results of previous studies and providing an up-to-date review.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs). The following seven databases were searched: MEDLINE, CINAHL, PsycINFO, ACM Digital Library, IEEE Xplore, Scopus, and Google Scholar. We also conducted backward and forward reference list checking for the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. We used a narrative and statistical approach, as appropriate, to synthesize the results of the included studies.

RESULTS

Of the 935 citations retrieved, 33 studies were included in this review. Of these, 22 RCTs were eventually included in the meta-analysis. Very low-quality evidence from 9 RCTs and 5 RCTs showed no statistically significant effect of exergames (games entailing physical exercises) on anxiety levels when compared with conventional exercises (P=.70) and no intervention (P=.27), respectively. Although 6 RCTs demonstrated a statistically and clinically significant effect of computerized cognitive behavioral therapy games on anxiety levels when compared with no intervention (P=.01), the quality of the evidence reported was low. Similarly, low-quality evidence from 3 RCTs showed a statistically and clinically significant effect of biofeedback games on anxiety levels when compared with conventional video games (P=.03).

CONCLUSIONS

This review shows that exergames can be as effective as conventional exercises in alleviating anxiety; computerized cognitive behavioral therapy games and exergames can be more effective than no intervention, and biofeedback games can be more effective than conventional video games. However, our findings remain inconclusive, mainly because there was a high risk of bias in the individual studies included, the quality of meta-analyzed evidence was low, few studies were included in some meta-analyses, patients without anxiety were recruited in most studies, and purpose-shifted serious games were used in most studies. Therefore, serious games should be considered complementary to existing interventions. Researchers should use serious games that are designed specifically to alleviate depression, deliver other therapeutic modalities, and recruit a diverse population of patients with anxiety.

Virtual Reality Aided Therapy towards Health 4.0: A Two-Decade Bibliometric Analysis

Health 4.0 aligns with Industry 4.0 and encourages the application of the latest technologies to healthcare. Virtual reality (VR) is a potentially significant component of the Health 4.0 vision. Though VR in health care is a popular topic, there is little knowledge of VR-aided therapy from a macro perspective. Therefore, this paper was aimed to explore the research of VR in aiding therapy, thus providing a potential guideline for futures application of therapeutic VR in healthcare towards Health 4.0. A mixed research method was adopted for this research, which comprised the use of a bibliometric analysis (a quantitative method) to conduct a macro overview of VR-aided therapy, the identification of significant research structures and topics, and a qualitative review of the literature to reveal deeper insights. Four major research areas of VR-aided therapy were identified and investigated, i.e., post-traumatic stress disorder (PTSD), anxiety and fear related disorder (A&F), diseases of the nervous system (DNS), and pain management, including related medical conditions, therapies, methods, and outcomes. This study is the first to use VOSviewer, a commonly used software tool for constructing and visualizing bibliometric networks and developed by Center for Science and Technology Studies, Leiden University, the Netherlands, to conduct bibliometric analyses on VR-aided therapy from the perspective of Web of Science core collection (WoSc), which objectively and visually shows research structures and topics, therefore offering instructive insights for health care stakeholders (particularly researchers and service providers) such as including integrating more innovative therapies, emphasizing psychological benefits, using game elements, and introducing design research. The results of this paper facilitate with achieving the vision of Health 4.0 and illustrating a two-decade (2000 to year 2020) map of pre-life of the Health Metaverse.

The Effectiveness of Serious Games for Alleviating Depression: Systematic Review and Meta-analysis

BACKGROUND

Depression is a common mental disorder characterized by disturbances in mood, thoughts, or behaviors. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological therapeutic intervention for depression. Previous systematic reviews have summarized evidence of effectiveness of serious games in reducing depression symptoms; however, they are limited by design and methodological shortcomings.

OBJECTIVE

This study aimed to assess the effectiveness of serious games in alleviating depression by summarizing and pooling the results of previous studies.

METHODS

A systematic review of randomized controlled trials (RCTs) was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search sources included 6 bibliographic databases (eg, MEDLINE, PsycINFO, IEEE Xplore), the search engine "Google Scholar," and backward and forward reference list checking of the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. Results of the included studies were synthesized narratively and statistically, as appropriate, according to the type of serious games (ie, exergames or computerized cognitive behavioral therapy [CBT] games).

RESULTS

From an initial 966 citations retrieved, 27 studies met the eligibility criteria, and 16 studies were eventually included in meta-analyses. Very low-quality evidence from 7 RCTs showed no statistically significant effect of exergames on the severity of depressive symptoms as compared with conventional exercises (P=.12). Very low-quality evidence from 5 RCTs showed a statistically and clinically significant difference in the severity of depressive symptoms (P=.004) between exergame and control groups, favoring exergames over no intervention. Very low-quality evidence from 7 RCTs showed a statistically and clinically significant effect of computerized CBT games on the severity of depressive symptoms in comparison with no intervention (P=.003).

CONCLUSIONS

Serious games have the potential to alleviate depression as other active interventions do. However, we could not draw definitive conclusions regarding the effectiveness of serious games due to the high risk of bias in the individual studies examined and the low quality of meta-analyzed evidence. Therefore, we recommend that health care providers consider offering serious games as an adjunct to existing interventions until further, more robust evidence is available. Future studies should assess the effectiveness of serious games that are designed specifically to alleviate depression and deliver other therapeutic modalities, recruit participants with depression, and avoid biases by following recommended guidelines for conducting and reporting RCTs.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42021232969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=232969.

Research on Athlete Behavior Recognition Technology in Sports Teaching Video Based on Deep Neural Network

In recent years, due to the simple design idea and good recognition effect, deep learning method has attracted more and more researchers' attention in computer vision tasks. Aiming at the problem of athlete behavior recognition in mass sports teaching video, this paper takes depth video as the research object and cuts the frame sequence as the input of depth neural network model, inspired by the successful application of depth neural network based on two-dimensional convolution in image detection and recognition. A depth neural network based on three-dimensional convolution is constructed to automatically learn the temporal and spatial characteristics of athletes' behavior. The training results on UTKinect-Action3D and MSR-Action3D public datasets show that the algorithm can correctly detect athletes' behaviors and actions and show stronger recognition ability to the algorithm compared with the images without clipping frames, which effectively improves the recognition effect of physical education teaching videos.

Are Australian Mental Health Services Ready for Therapeutic Virtual Reality? An Investigation of Knowledge, Attitudes, Implementation Barriers and Enablers

Therapeutic virtual reality (VR) has the potential to address the challenges of equitable delivery of evidence-based psychological treatment. However, little is known about therapeutic VR regarding the perspectives and needs of real-world service providers. This exploratory study aimed to assess the acceptability, appropriateness, and feasibility of therapeutic VR among clinicians, managers, and service staff working in mental healthcare and explore potential implementation barriers and enablers. Eighty-one staff from a network of private psychiatric hospitals in Victoria, Australia (aged M + SD: 41.88 + 12.01 years, 71.6% female; 64% clinical staff) completed an online survey, which included the Acceptability of Intervention Measure (AIM), Appropriateness of Intervention Measure (IAM), and Feasibility of Intervention Measure (FIM). While 91% of participants had heard about VR technology, only 40% of participants had heard of therapeutic VR being used in mental healthcare, and none had used therapeutic VR in a clinical setting. Most participants perceived VR to be acceptable (84%), appropriate (69%), and feasible (59%) to implement within their role or service and envisioned a range of possible applications. However, participants expressed concerns regarding safety, efficacy, and logistical challenges across clinical settings. Findings suggest a strong interest for therapeutic VR among Australian mental health providers working in the private system. However, dissemination efforts should focus on addressing identified barriers to ensure mental health providers are adequately informed and empowered to make implementation decisions.

A Decade in Review: A Systematic Review of Virtual Reality Interventions for Emotional Disorders

Research is increasingly demonstrating the therapeutic benefits of virtual reality interventions for various mental health conditions, though these rarely translate from research to application in clinical settings. This systematic review aims to examine the efficacy of current virtual reality interventions for emotional disorders, with a focus on clinical and technological features that influence translation of treatments from research to clinical practice. A comprehensive systematic literature search was conducted following PRISMA guidelines, for studies including the application of a virtual reality intervention to a clinical population of adults with an emotional disorder. Thirty-seven eligible studies were identified, appraised, and assessed for bias. Treatment effects were typically large across studies, with virtual reality being considered an efficacious treatment modality for various anxiety disorders and post-traumatic stress disorder. Virtual reality interventions were typically used for delivering exposure in cognitive behavioural therapy approaches. Considerable variability was seen in cost, technological specifications, degree of therapist involvement, delivery format, dosage, duration, and frequency of treatment. Suboptimal methodological rigour was identified in some studies. Remote use of virtual reality was rare, despite increasing options for in home use. Virtual reality interventions have the potential to overcome barriers to care and better meet the needs of consumers. Future research should examine the efficacy of virtual reality for treatment of depressive disorders and obsesive compulsive disorder. Improved methodological reporting and development of transdiagnostic and remotely delivered virtual reality interventions, will likely increase the translation of this treatment modality.

Effectiveness of Self-Guided Virtual Reality-Based Cognitive Behavioral Therapy for Panic Disorder: Randomized Controlled Trial

BACKGROUND

Virtual reality (VR) is as effective a technique as traditional cognitive behavioral therapy (CBT) and a promising tool for treating panic disorder symptoms because VR exposure can be safer and has better acceptability than in vivo exposure and is more immersive than exposure through imagination. CBT techniques can be delivered more effectively using VR as well. So far, VR has required high-quality devices, but the development of mobile VR technology has improved user availability. At the same time, a well-structured form of VR can be reproduced and used anywhere. This means that VR can be used to provide a self-guided form of treatment and address the high treatment costs of evidence-based therapy and the lack of professional therapists. This study aimed to investigate the potential of self-guided VR as an alternative to high-cost treatment.

OBJECTIVE

The main goal of this study was to offer data about the efficacy of a mobile app-based self-led VR CBT in the treatment of panic disorder.

METHODS

A total of 54 subjects with panic disorder were enrolled in this study and randomly assigned to either the VR treatment group or waitlist group. The VR treatment was designed to be total 12 sessions for 4 weeks. The VR treatment consists of 4 steps in which patients are gradually exposed to phobic stimuli while learning to cope with panic symptoms in each stage. The effectiveness of treatment was assessed through the Panic Disorder Severity Scale, Hamilton Rating Scale for Depression, Body Sensations Questionnaire, Albany Panic and Phobia Questionnaire, Anxiety Sensitivity Index, State-Trait Anxiety Inventory, Hospital Anxiety and Depression Scale, Korean Inventory of Social Avoidance and Distress Scale, Korean Inventory of Depressive Symptomatology, and Perceived Stress Scale. In addition, physiological changes using heart rate variability were evaluated.

RESULTS

In within-group analyses, the VR treatment group exhibited improvements in panic disorder symptoms, anxiety, and depression after 4 weeks, while the waitlist group did not show any significant improvement. Compared to the waitlist group, the VR treatment group showed significantly greater improvements in the Panic Disorder Severity Scale in both completer analysis and intention-to-treat analysis. Heart rate variability in the VR treatment group showed improvement in normalized high frequency from baseline to postassessment with no significant differences in any outcome measure between groups.

CONCLUSIONS

The self-guided, mobile app-based VR intervention was effective in the treatment of panic symptoms and restoring the autonomic nervous system demonstrating the validity of the use of VR for self-guided treatment. VR treatment can be a cost-effective therapeutic approach.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04985019; https://clinicaltrials.gov/ct2/show/NCT04985019.

Virtual Reality for the Treatment of Anxiety Disorders: A Scoping Review

IMPORTANCE

Virtual reality in head-mounted displays (HMD-VR) may be a valuable tool in occupational therapy to address anxiety. Findings from the virtual reality exposure therapy (VRET) literature may facilitate translation of HMD-VR to occupational therapy psychosocial practice.

OBJECTIVE

To explore how HMD-VR has been used to treat anxiety through VRET and could be translated to occupational therapy.

DATA SOURCES

We searched seven electronic databases for articles published between 2000 and 2020: CINAHL, Cochrane Library, Embase, ERIC, Ovid MEDLINE, PsycINFO, and Web of Science. Search terms included HMD-VR constructs, products, and therapy concepts. Study Selection and Data Collection: We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to report studies implementing VRET to treat anxiety. At least two reviewers assessed each citation, and a third resolved disagreements. Articles were included if they were in English, reported experimental data, and used HMD-VR. Letters, commentaries, book chapters, technical descriptions, theoretical papers, conference proceedings (≤4 pages), and reviews were excluded.

FINDINGS

Twenty-eight studies used HMD-VR to treat posttraumatic stress disorder (n = 3), specific phobias (n = 19), and performance-based social anxiety (n = 6); protocols and levels of evidence varied (randomized controlled trials, n = 11; controlled trials without randomization, n = 6; case-control or cohort studies, n = 11). Qualitative examination indicates HMD-VR is an effective treatment tool.

CONCLUSIONS AND RELEVANCE

HMD-VR can be a valuable tool for occupational therapy to simulate environments where clients with anxiety disorders participate. Eliciting presence through multisensory features and body representation may enhance outcomes. What This Article Adds: Drawing from the VRET literature, this scoping review suggests that HMD-VR can be used by occupational therapy practitioners to simulate ecologically valid environments, evaluate client responses to fearful stimuli, and remediate anxiety though immersion in virtual tasks when participation in natural contexts is unfeasible. Having ecologically valid environments is particularly important for people with anxiety disorders because they need support to cope when they encounter triggers in everyday life environments.

Provider experiences of virtual reality in clinical treatment

Background

Virtual reality (VR) has proven effective in the treatment of specific phobias and trauma particularly when in-vivo exposure therapy might be costly (e.g. fear of flying, combat scenes). Similarly, VR has been associated with improvement of chronic pain and of acute pain during medical procedures. Despite its effectiveness as a healthcare tool, VR technology is not well-integrated into common practice. This qualitative study aims to explore the provider perception of the value of VR and identify barriers to VR implementation among healthcare providers.

Methods

A 66-item self-report survey was created to examine application of VR to clinical practice, perceived value of this treatment, ease of learning the technology, billing considerations, and other obstacles. 128 providers (MDs and PhDs) who were located in the United States and had used VR as a therapeutic tool in the past year were identified through research papers, as well as user lists and news articles from VR application websites. Of the 128 providers contacted, 17% (22) completed our online self-report measure. Of these, 13% of respondents (N = 17) completed greater than 75% of the questionnaire and were considered completers. Provider responses were collected over a one-month period and qualitatively analyzed.

Results

The majority of providers were from an academic institution (n = 12, 70.6%), and all providers practiced in the outpatient setting. Providers most commonly reported using VR for the treatment of acute pain and/or anxiety related to medical procedures (n = 11, 64.7%), followed by specific phobia (n = 6, 35.3%) and social phobia (n = 6, 35.3%). All providers agreed VR is a valuable tool they would recommend to colleagues. The majority (n = 15, 93.8%) believed VR helped their patients progress in treatment, compared with other methods. Providers cited the ability to individualize treatment (n = 14, 87.5%) and increase patient engagement (n = 15, 93.8%) as main benefits of VR. A minority reported negative feedback from patients about content (n = 4, 25%) or about the technology in general (n = 6, 37.5%), whereas all reported some form of positive feedback. The slight majority (n = 10, 58.8%) of providers did not find transitioning to VR difficult. Of those who did, cost was the most commonly cited barrier (n = 6). Regarding reimbursement, only 17.6% (n = 3) of providers reported the ability to bill for VR sessions. Most providers (n = 15, 88.2%) received training on their VR platform which they found beneficial. Comparing the trained and untrained groups found no significant difference in VR comfort level (p = 0.5058), the value of VR in practice (p = 0.551) or whether providers would recommend VR to others (p = 0.551), though sample sizes were small.

Conclusions

In corroboration with previous research, this study demonstrates that VR is well-received by patients and providers, allowing increased patient engagement and treatment individualization. However, associated costs, including an inability to bill for this service, can present a barrier to further implementation. These findings will guide further development of virtual reality as a standardized tool in psychiatry and pain management.

"Like I'm Talking to a Real Person": Exploring the Meaning of Transference for the Use and Design of AI-Based Applications in Psychotherapy

AI-enabled virtual and robot therapy is increasingly being integrated into psychotherapeutic practice, supporting a host of emotional, cognitive, and social processes in the therapeutic encounter. Given the speed of research and development trajectories of AI-enabled applications in psychotherapy and the practice of mental healthcare, it is likely that therapeutic chatbots, avatars, and socially assistive devices will soon translate into clinical applications much more broadly. While AI applications offer many potential opportunities for psychotherapy, they also raise important ethical, social, and clinical questions that have not yet been adequately considered for clinical practice. In this article, we begin to address one of these considerations: the role of transference in the psychotherapeutic relationship. Drawing on Karen Barad’s conceptual approach to theorizing human–non-human relations, we show that the concept of transference is necessarily reconfigured within AI-human psychotherapeutic encounters. This has implications for understanding how AI-driven technologies introduce changes in the field of traditional psychotherapy and other forms of mental healthcare and how this may change clinical psychotherapeutic practice and AI development alike. As more AI-enabled apps and platforms for psychotherapy are developed, it becomes necessary to re-think AI-human interaction as more nuanced and richer than a simple exchange of information between human and nonhuman actors alone.

Pilot randomized trial of self-guided virtual reality exposure therapy for social anxiety disorder

BACKGROUND

Virtual reality exposure therapy (VRE) has shown promising efficacy for the treatment of social anxiety disorder (SAD) and related comorbidities. However, most trials conducted to date were therapist-led, and little is known about the efficacy of self-guided VRE. Therefore, this randomized controlled trial (RCT) aimed to determine the efficacy of a self-directed VRE for SAD.

METHOD

Forty-four community-dwelling or undergraduate adults diagnosed with SAD based on the Mini International Neuropsychiatric Interview were randomly assigned to VRE designed to last four sessions or more (n = 26) or waitlist (WL; n = 18). Self-reported SAD severity (Social Phobia Diagnostic Questionnaire and Social Interaction Anxiety Scale), job interview anxiety (Measure of Anxiety in Selection Interviews), trait worry (Penn State Worry Questionnaire), and depression symptoms (Patient Health Questionnaire-9) were administered at baseline, post-treatment, 3-month-follow-up (3MFU), and 6-month-follow-up (6MFU). Piecewise multilevel modeling analyses were conducted to manage clustering in the data.

RESULTS

VRE vs. WL resulted in greater reductions in SAD symptom severity, job interview fear, and trait worry, with moderate-to-large effect sizes (Hedge's g = -0.54 to -1.11) from pre-to-post treatment. Although significant between-group differences did not emerge for change in depression, VRE led to change in depression, whereas waitlist did not. These gains were also maintained at 3MFU and 6MFU. Further, facets of presence increased during the course of VRE (g = 0.36-0.45), whereas cybersickness decreased (g = -0.43).

DISCUSSION

Brief, self-guided VRE might ameliorate SAD and comorbid worry, for young-to-middle-aged adults with SAD. Other theoretical and practical implications were also discussed.

Internet- and mobile-based interventions for the treatment of specific phobia: A systematic review and preliminary meta-analysis

Internet- and mobile-based interventions (IMIs) are being developed for a wide range of psychological disorders and they showed their effectiveness in multiple studies. Specific phobia (SP) is one of the most common anxiety disorders, and research about IMIs for their treatment has also been conducted in recent years. The aim of this paper was to conduct a systematic review and preliminary meta-analysis exploring IMIs for the treatment of SP. A comprehensive search conducted in five different databases identified 9 studies (4 pre-post studies, 5 randomized controlled trials) with 7 Internet-based interventions and 2 mobile-based interventions. Results showed that exposure was the main component of all interventions, and that animal phobia was the most common subtype. Samples included children, adolescents, and adults. A preliminary meta-analysis of the included studies showed that participants receiving IMIs experienced a significant reduction of SP symptoms from pre- to post-treatment (g = 1.15). This systematic review found that there is already some evidence in the literature supporting the potential benefits of IMIs for SP. However, the number of studies included is small and more research should be carried out in the field.

Pivoting to "No Contact": A Protocol for Conducting a Virtual Reality Relaxation Home Study for Teens Amidst the COVID-19 Pandemic

Prior to the COVID-19 pandemic, our team planned to pilot a self-administered virtual reality environment for stress reduction. The purpose of this manuscript is to describe our pivot to a "no contact" protocol, including participant feedback and lessons learned. Our protocol included virtual reality study kit sanitization, delivery, and return; remote screening, consent, enrollment, and data collection; and virtual study visits. All study participants found the protocol to be acceptable. Lessons learned include strategies for institutional review board approval and improved orientation to the study technology. Despite a global pandemic, our "no contact" protocol was feasible and acceptable.

The Effectiveness of Serious Games in Alleviating Anxiety: Systematic Review and Meta-analysis (Preprint).. [DOI: 10.2196/preprints.29137]

BACKGROUND

Anxiety is a mental disorder characterized by apprehension, tension, uneasiness, and other related behavioral disturbances. One of the nonpharmacological treatments used for reducing anxiety is serious games, which are games that have a purpose other than entertainment. The effectiveness of serious games in alleviating anxiety has been investigated by several systematic reviews; however, they were limited by design and methodological weaknesses.

OBJECTIVE

This study aims to assess the effectiveness of serious games in alleviating anxiety by summarizing the results of previous studies and providing an up-to-date review.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs). The following seven databases were searched: MEDLINE, CINAHL, PsycINFO, ACM Digital Library, IEEE Xplore, Scopus, and Google Scholar. We also conducted backward and forward reference list checking for the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. We used a narrative and statistical approach, as appropriate, to synthesize the results of the included studies.

RESULTS

Of the 935 citations retrieved, 33 studies were included in this review. Of these, 22 RCTs were eventually included in the meta-analysis. Very low–quality evidence from 9 RCTs and 5 RCTs showed no statistically significant effect of exergames (games entailing physical exercises) on anxiety levels when compared with conventional exercises (<i>P</i>=.70) and no intervention (<i>P</i>=.27), respectively. Although 6 RCTs demonstrated a statistically and clinically significant effect of computerized cognitive behavioral therapy games on anxiety levels when compared with no intervention (<i>P</i>=.01), the quality of the evidence reported was low. Similarly, low-quality evidence from 3 RCTs showed a statistically and clinically significant effect of biofeedback games on anxiety levels when compared with conventional video games (<i>P</i>=.03).

CONCLUSIONS

This review shows that exergames can be as effective as conventional exercises in alleviating anxiety; computerized cognitive behavioral therapy games and exergames can be more effective than no intervention, and biofeedback games can be more effective than conventional video games. However, our findings remain inconclusive, mainly because there was a high risk of bias in the individual studies included, the quality of meta-analyzed evidence was low, few studies were included in some meta-analyses, patients without anxiety were recruited in most studies, and purpose-shifted serious games were used in most studies. Therefore, serious games should be considered complementary to existing interventions. Researchers should use serious games that are designed specifically to alleviate depression, deliver other therapeutic modalities, and recruit a diverse population of patients with anxiety.

Virtuelle Realität bei Angsterkrankungen – vom experimentellen Tool zur klinischen Praxis

Anxiety disorders are among the most frequent psychiatric disorders. According to national and international guidelines, psychopharmacological as well as psychotherapeutic approaches are recommended as first-choice treatments, depending on diagnosis and severity. Among psychotherapeutic approaches, cognitive-behavioral therapy (CBT) has been investigated most. Here, exposure is of special relevance as the core element of treatment. The technology of virtual reality (VR) has been increasingly investigated as a possible add-on strategy or alternative to conventional exposure therapy. Numerous studies of VR exposure for anxiety disorders have been published. Further, the comparison of exposure treatment in vivo vs. in VR has been investigated in meta-analyses. The results are promising overall, however they do not yet justify a general recommendation of this treatment. There is still the need for more research, especially regarding treatment efficacy in large-scale studies with larger patient samples.

Integrating virtual realities and psychotherapy: SWOT analysis on VR and MR based treatments of anxiety and stress-related disorders

The use of virtual reality (VR) and mixed reality (MR) technology in clinical psychology is growing. Efficacious VR-based treatments for a variety of disorders have been developed. However, the field of technology-assisted psychotherapy is constantly changing with the advancement in technology. Factors such as interdisciplinary collaboration, consumer familiarity and adoption of VR products, and progress in clinical science all need to be taken into consideration when integrating virtual technologies into psychotherapies. We aim to present an overview of current expert opinions on the use of virtual technologies in the treatment of anxiety and stress-related disorders. An anonymous survey was distributed to a select group of researchers and clinicians, using an analytic framework known as Strengths, Weaknesses, Opportunities, and Threats (SWOT). Overall, the respondents had an optimistic outlook regarding the current use as well as future development and implementation of technology-assisted interventions. VR and MR psychotherapies offer distinct advantages that can overcome shortcomings associated with traditional therapy. The respondents acknowledged and discussed current limitations of VR and MR psychotherapies. They recommended consolidation of existing knowledge and encouraged standardisation in both theory and practice. Continued research is needed to leverage the strengths of VR and MR to develop better treatments.Abbreviations: AR: Augmented Reality; MR: Mixed Reality; RCT: Randomised Controlled Trial; SWOT: Strengths, Weaknesses, Opportunities, and Threats; VR: Virtual Reality; VR-EBT: Virtual Reality Exposure-Based Therapy.